Please help me-colonoscopy

AR2728

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The hospital billing department and myself (I code physician) are in a heated debate with my physician. Our stance is that if the physician documents a PREOPERATIVE condition, hemorrhoids, rectal bleeding, constipation, on the operative colonoscopy report that the colonscopy should not be billed as screening. Mind you-he also lists a diagnosis of screening colonscopy as preop. He is stating that just because he lists a preoperative diagnosis that does not warrant or indicate a need for a colonoscopy. My feelings...I truly believe (especially in light of the mandated preventive insuranc coverage), that inusurance companies will argue that a preop diagnosis overides the screening and should be billed as such. I'm looking for any further documentation. This physician will argue to the death, he had some coding education YEARS ago and feels he is always correct. Our last conversation he told me that he code bill it however he wanted! What do I do with this? In some of these cases he is listing diarrhea as a preoperative diagnosis, but then I read the H&P and it clearly states that the patient had diarrhea in the past when he ate lettuce--but yet he lists this as a current condition on the operative report. So, I have an additional question----if he lists hemorrhoids (not a covered diagnosis for Medicare) should this colonoscopy be billed screening? Is there a list of specific diagnostic indications for colonoscopy---and if the symptom is not on that list should it be screeing? He's got me second quessing everything I've learned. Please Help me!
April
 

mitchellde

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The provider may list issues that the patient has indicated they have a history of and I agree that just because it is listed does not make it a reason for the colonoscopy. You need to have a place where it identified as the indication for the study if the patient indicates they are here for a screening, even if they have had a past history of issues then this is still a screening. These are not then necessarily pre operative conditions just prior concerns or conditions that are not relevant at this point in time, just something for the physician to keep in mind while observing during the screening. Maybe this can help?
 

KarenD

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screening colonoscopy

We have the same confusion as you do when billing screening colonoscopies. Some carriers have specific guidelines for screening (Medicare), as well as others. If the physician lists a pre-op diagnosis (ex. 569.3 or 564.00) then it should not be billed as screening. Also ask why the procedure scheduled? If screening, then use V76.51 as primary, and then code the other diagnoses, colon polyp, etc. This continues to be a "can of worms" and pt's preventative benefits vs. diagnostic benefits have them calling the office all the time to question the claim.
Have you ever heard.... YOU billed it wrong?? I bet we hear that every day, many times.
Good luck
Karen K.
 

AR2728

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Our biggest confusion comes into play when he is documenting their past GI history on the operative report as a current symptom-as in the diarrhea-not stating that this is a history. I have gotten to the point where I review the H&P prior to coding the colonoscopy to verify the reason patient presented and whether the said preop diagnosis is truly current or reflects the patients history of issues. My concern of course, is that a request of the operative report to the insurance company will contradict what we billed. I feel like I'm caught between a rock and a hard place. His feeling is that someone having rectal bleeding doesn't necessary mean that the colonscopy is diagnostic-yet this is not the insurance companies view of the guidelines. That's exactly the problem, what the physician thinks vs the insurance company, and the messanger is the one who gets shot. I'm not sure if I will find a resolve to this issue. And, yes, we receive frequent calls on billing/coding incorrectly-after all, that's what their insurance company told them-so it must be true. I appreciate feedback...sometimes its nice just to know your not alone.
 

mitchellde

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I always remember to focus on the patient and not the claim, as in the claim has to reflect the reason for the encounter as the documentation states and not what the claim will reflect for payment. Because in the end we will need to justify our choices based on what the documentation can support.
 

mdimitrov

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A reference for you

Hi April,

It's often difficult to determine the correct way to code a scenario without reviewing the documentation...The way the doctor documents is ultimately the determining factor of correct coding. The statements you're using in these posts and some of the responses from other contributors are not clear enough to provide an answer that will always be right in all patient scenarios.

I found this article that I feel will be very helpful to you, your patients and your physicians, in clearing up some of the confusion and debate regarding the difference between screening and diagnostic procedures, along with some examples.

http://www.gastro.org/journals-publications/gi-quality-and-practice-management-news/2011/screening-versus-diagnostic-colonoscopy-what-you-your-patients-and-referring-physicians-should-know

I hope this helps!


MaryAnn Dimitrov, CCS, CCS-P, CPC, CPC-H, AHIMA-Approved ICD-10-CM/PCS Trainer,
President, Medical Basix
md@medicalbasix.com
 

syllingk

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April,
I get many many phone calls from patients saying their insurance says I coded it wrong.
Also I always look at the h&p and the path before I code the scope.
Especially paying close attention to the patients chief complaint.
You are not alone!
 

AthensCoder

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Coding Colonscopies

Hi everyone!

I'm have the same problem with patients and isurance tell them that it was coded wrong. What I do is I educate the patients and the meaning of a screening colonoscopy; i.e NO PROBLEMS = screening. If they are coming in because of issues; such as, constipation, rectal bleeding, etc...Then it is not a screening it is a diagnostic because they are presenting with problems and the reason for the colonoscopy is to determine WHY they are having these problems. Also is a patient preents for a screenign colonoscopy and then polys are found u attach they PT modifier so that the insurance carrier knows it was initial a screening colonoscopy converted to a diagnostic.
 

AR2728

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I'm so glad I'm not the only one having problems, I appreciate all the responses. We (office staff) had wished to do some patient education prior to the scope being performed, our physician was not impressed by this at all. I now refer back to the H&P frequently, and why the patient presented to the office. It does help, but does not alleviate all questions.
 
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